QUALITY MANAGEMENT PLAN FOR THE DEPARTMENT OF ENVIRONMENTAL QUALITY WATER DIVISION

Transcription

1 QUALITY MANAGEMENT PLAN FOR THE DEPARTMENT OF ENVIRONMENTAL QUALITY WATER DIVISION Commonwealth of Virginia Department of Environmental Quality 629 East Main Street P.O. Box 1105 Richmond, VA 23219

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3 QUALITY ASSURANCE MANAGEMENT PLAN IDENTIFICATION FORM Document Tile: Document Control Number: Organization Title: Address: Responsible Official: Title: Quality Management Plan for the Department of Environmental Quality, Office of Water Monitoring and Assessment. VADEQ WQMA\004 Department of Environmental Quality 629 East Main Street Richmond, VA David Paylor Director, Virginia Department of Environmental Quality Quality Assurance Coordinator: James Beckley Phone: (804) Plan Coverage: This plan describes Virginia Department of Environmental Quality policy and commitment to develop and implement a quality assurance management plan for water quality monitoring sample collection, sample analyses, and the handling of environmental data generated or processed in support of water quality assessment. The quality assurance criteria covered in this plan apply to intramural and extramural environmental monitoring. 3

4 QUALITY ASSURANCE MANAGEMENT PLAN APPROVALS (1) Name: James Beckley Title: Quality Assurance Coordinator - VADEQ Signature: Date: (2) Name: Darryl M. Glover Title: Manager, Office of Water Monitoring and Assessment - VADEQ Signature: Date: (3) Name: David Lazarus Title: Manager, Watershed Programs VADEQ Signature: Date: (4) Name: Frederick Cunningham Title: Manager, Office of Water Permits and Compliance Assistance VADEQ Signature: Date: (5) Name: Alan E. Pollock Title: Manager, Office of Water Quality Programs - VADEQ Signature: Date: (6) Name: Ellen Gilinsky, Ph.D. Title: Director, Water Division - VADEQ Signature: Date: (7) Name: Terry Simpson Title: Region 3 Quality Assurance Manager - USEPA Signature: Date: 4

5 TABLE OF CONTENTS Revision: 7 LIST OF ACRONYMS MANAGEMENT AND ORGANIZATION INTRODUCTION GOALS POLICY QUALITY ASSURANCE MANAGEMENT ASSIGNMENT OF RESPONSIBILITIES Roles and Responsibilities: Contract Program Manager Responsibilities: Organizational Responsibilities: QUALITY SYSTEM COMPONENTS PRINCIPLE COMPONENTS AND TOOLS OF THE QUALITY MANAGEMENT SYSTEM Quality Management Plan (QMP) Data Quality Objectives Quality Assurance Project Plans Standard Operating Procedures Quality Assurance (QA) Status Reports PERSONNEL QUALIFICATION AND TRAINING TRAINING POLICY TRAINING QUALIFICATIONS AND DOCUMENTATION CONTINUED PROFICIENCY LABORATORY PERSONNEL TRAINING PROCUREMENT OF ITEMS AND SERVICES DOCUMENTS AND RECORDS IDENTIFICATION OF QUALITY-RELATED DOCUMENTS AND RECORDS MAINTENANCE OF RECORDS COMPUTER HARDWARE AND SOFTWARE PLANNING PLANNING GOALS AND OBJECTIVES IDENTIFICATION OF DATA USERS AND SUPPLIERS SCHEDULING AND RESOURCES PERFORMANCE CRITERIA QA/QC ACTIVITIES EXTERNAL DATA ANALYSIS, EVALUATION AND ASSESSMENT OF DATA QAPP REVIEWING, APPROVING, AND REVISING IMPLEMENTATION OF WORK PROCESSES OPERATING POLICIES AND PROCEDURES PROGRAM IMPLEMENTATION SOP IMPLEMENTATION IMPLEMENTATION OF THE ANALYTICAL METHODS MANUAL ASSESSMENT AND RESPONSE REVIEW OF VADEQ QUALITY ASSURANCE PROGRAM TECHNICAL SYSTEMS AUDITS (TSAS)

6 9.2.1 Laboratory TSAs Field TSAs Performance Evaluations DATA QUALITY EVALUATIONS Data Quality assessments Data Completeness QUALITY IMPROVEMENT...30 LIST OF FIGURES FIGURE 1 WD MONITORING & PERMITTING ACTIVITIES ORGANIZATIONAL CHART FIGURE 2 DCLS ORGANIZATION CHART LIST OF APPENDIXES APPENDIX A TITLE OF SOPS AND THEIR LOCATIONS...32 APPENDIX B DATA QUALITY ASSESSMENT SOP AND CHECKLIST

7 List of Acronyms CEDS DCLS DQA DQO EPA NELAC OIS OWP QA QAPP QA/QC QC QMP SOP TSA WD WQM WMA VADEQ Revision: 7 Comprehensive Environmental Data System Division of Consolidated Laboratory Services Data Quality Assessment Data Quality Objective Environmental Protection Agency National Environmental Laboratory Accreditation Conference Office of Information Services Office of Water Quality Programs Quality Assurance Quality Assurance Project Plan Quality Assurance/Quality Control Quality Control Quality Management Plan Standard Operating Procedure Technical System Audit Water Division Water Quality Monitoring Water Monitoring Assessment Program Virginia Department of Environmental Quality 7

8 1.0 Management and Organization 1.1 Introduction The Commonwealth of Virginia Department of Environmental Quality (VADEQ) is mandated by the State Water Control Law (Chapter 3.1 Title 62.1 of Code of Virginia section ) to protect existing high quality state waters and to provide for the restoration of all other state waters. In accordance with this mandate, the VADEQ established procedures for investigating, monitoring and scientifically evaluating water quality and water problems. The management and staff of VADEQ are committed to producing environmental data and technology consistent with the guidelines presented in the Quality Management Plan (QMP). Adherence to quality system requirements assures that environmental data and technology is suitable for the technical decision making process, protection of the environment, and management of the VADEQ mission. The purpose of this QMP is to document management policies, goals, objectives and general procedures by which the VADEQ produces and validate acceptable water quality data. Implementation of this plan within the various field and laboratory water quality monitoring and measurement program efforts ensures that decisions made by the agency affecting the Commonwealth s water quality are based upon sound professional principles and environmental data of known and acceptable quality. This QMP defines and describes the quality assurance and quality control policies and responsibilities prescribed by the Water Division (WD) in accordance with USEPA Order Policy and Program Requirement to Implement the Mandatory Quality Assurance Program, USEPA QA/R-1 EPA Quality Assurance Requirements for Quality Management Programs, and USEPA QA/R-2 EPA Requirements for Quality Management Plans. This document links the management policies, objectives and principles of the program with the procedures described in associated Quality Assurance Project Plans (QAPPs) and Standard Operating Procedures (SOPs) which are designed to produce data of known quality. These policies should guide the Project Manager in the uniform implementation of QA/QC requirements for all monitoring programs. This QMP covers the collection of water quality samples and data for VADEQ s Water Division. Programs collecting samples and data in the WD include VADEQ s Water Quality Standards and Biological Program, Water Monitoring and Assessment Program, the Total Maximum Daily Loads Watershed Program, and the Permitting Water Compliance Program. 1.2 Goals The goals of the VADEQ s Water Division QA systems are: (a) To ensure that all environmental data generated by or for the agency that will be utilized to evaluate water quality is scientifically valid, defensible and of documented and adequate quality. 8

9 (b) To ensure that all water quality monitoring activities performed by or under contract for VADEQ have approved QAPPs prior to the start of collection activities. (c) To maintain communication on QA issues and activities among management and staff. (d) To perform assessments to determine the effectiveness of the WD quality assurance system. Continued improvement in the quality management system is emphasized. (e) To accomplish QA processes in the most cost-effective manner without compromising data quality. 1.3 Policy It is the intent of the VADEQ WD to implement the following quality assurance policy: a) To ensure data generators produce quality data by providing easy access to all necessary documentation and QA training. b) Where applicable, ensure staff and external organization generating WQM data follow the requirements outlined in the QMP, subsequent WQM policy and standard operating procedures. c) To require a QAPP that describes intended data use, specific quality assurance activities, level of quality to be obtained and data acceptance criteria for field, laboratory and data management activities. These plans are approved prior to and implemented upon initiation of the water quality monitoring program for which they are intended. d) To ensure sufficient resources are allocated to guarantee that QA activities provide the desired level of quality. e) To conduct annual Technical System Audits (TSA) on monitoring staff and laboratory personnel and contractors to ensure that they comply with the WQM quality management system requirements and to address any highlighted deficiencies in a timely manner. 1.4 Quality Assurance Management The VADEQ recognizes the importance of the quality assurance to all aspects of its program and activities. Quality assurance is an integral part of the agency management plan and receives strong management support. A Quality Assurance Coordinator is assigned accountability for the management of the WD quality assurance program. The quality assurance coordinator is provided with resources to develop and implement associated program activities. 9

10 1.5 Assignment of Responsibilities The VADEQ Water Division and the Division of Consolidated Laboratory Services (DCLS) are responsible for their respective sampling and analytical programs. The organizational and management responsibilities, responsible individuals and organizational structures for these agencies are provided in Figures 1 and Roles and Responsibilities: Division Director: The Division Director has the overall responsibility for managing the QA program within the agency in accordance with the VADEQ QMP. The Director has the authority to ensure that adequate resources are provided to support the WD QA program responsibilities. Program Managers: The Program Managers coordinate staff to ensure implementation of the quality management system where environmental measurements are to occur. Regional Office Program Managers: a) Implement and oversee the WD QA policies within regional offices. b) Disseminate QA information within regional offices. c) Assist in the development of QA policies and procedures. d) Assist in solving QA related problems Quality Assurance Coordinator: a) Provide general management of the VADEQ WD quality assurance programs. b) Identify and respond to QA and QC needs, resolve problems, and answer requests for guidance and assistance. c) Provide assistance to VADEQ staff and external data generators in quality assurance related matters (i.e. study design, method selection). d) Develop or assist in the development of major program area project plans. e) Provide guidance and assistance to Project Managers and external data generators in the development and implementation of specific QAPPs. f) Review and approve all internally and externally generated QAPPs. 10

11 g) Identify program specific QA related training needs. h) Perform QA system audits systematic on-site qualitative review of facilities, equipment, training, procedures, record keeping, data validation, data management, and the reporting aspects of the total QA system. The audits are designed to insure that the QA program and QAPPs contain approved sample handling and analytical procedures and that those procedures are in use. i) Conduct QA performance audits quantitative analyses or checks with reference samples to determine the accuracy of a measurement system. j) Review analytical data and support the collection of QA data to insure that only data of known quality and integrity are available for entry into the database. k) Provide and obtain technical assistance from U.S. EPA quality assurance personnel. l) Review external project proposals to determine the need for a QAPP. m) Provide independent reviews of all regional and contractual QA/QC practices while maintaining open communication with regional and contractual personnel Contract Program Manager Responsibilities: a) QAPP development, implementation, evaluation, and reporting. b) Identification and reporting of QA problems and needs to VADEQ Quality Assurance Coordinator as they occur Organizational Responsibilities: The VADEQ WD has overall management responsibility including: a) Program design. b) Sample collection, preservation and handling. c) Field analysis. d) Field quality control. e) Data interpretation. f) Record keeping and reporting (shared responsibility). g) Data entry, validation, and reduction (shared responsibility). 11

12 DCLS has the overall responsibility for sample analysis including: a) Laboratory related quality assurance program and project plans. b) Sample analysis. c) Method evaluation and selection. d) Determination of accuracy and precision. e) Participation in U.S. EPA and/or NELAC system and performance audits. f) Record keeping and reporting (shared responsibility). g) Data entry, validation and reduction (shared responsibility). 1.6 Communications The program QA Officers shall notify the Program Managers of any identified problem areas. Corrective action will be taken as needed. A follow-up review of the corrective action will be made by the program QA Officer and the Program Managers to verify that problems have been resolved. Formal lines of communication regarding the quality assurance program status and needs are essential to ensure that an effective quality assurance program is implemented within VADEQ. The Quality Assurance Coordinator or designee will have direct access to VADEQ and DCLS management on quality assurance matters. The WD will also provide training on an on-going basis in order to ensure that VADEQ personnel responsible for QA functions understand the QA requirements and practices related to their responsibilities. 12

13 Figure 1 WD Monitoring & Permitting Activities Organizational Chart Director, DEQ Director, Water Division Regional Directors Water Quality Programs Manager Watershed and TMDL Program Manager Water Permits and Compliance Assistance Manager Water Monitoring and Assessment Manager Quality Assurance Coordinator (where applicable) Blue Ridge RO Field Manager Northern RO Field Manager Piedmont RO Field Manager Southwest RO Field Manager Tidewater RO Field Manager Valley RO Field Manager 13

14 Figure 2 DCLS ORGANIZATION CHART Revision: 7 14

15 2.0 QUALITY SYSTEM COMPONENTS Revision: 7 The VADEQ WD requires the following: a) Each special study project generating environmental data will develop and implement a QAPP that addresses the required major elements and will ensure that adequate resources (both monetary and staff) are provided to support the QA effort. The QA project plan will specify the detailed procedures required to assure quality data. The program QA Officers must approve QA project plans prior to data collection. b) All environmental data generated for the water quality monitoring program will be of known and acceptable quality as defined in the data quality objectives. The data quality information developed with all environmental data will be documented and available. c) All EPA and state funded environmental data collection efforts will ensure that acceptable QA requirements are included and implemented. d) The intended use of the data is defined before the data collection effort begins, so that appropriate QA measures may be applied to ensure a level of data quality commensurate with the monitoring objectives. The determination of this level of data quality shall also consider the prospective data needs of secondary users. Data quality objectives are established to ensure the utility of monitoring data meets its intended uses and as guidance for preparation of QA project plans. The intended data uses, level of quality, specific QA activities, and data acceptance criteria needed to meet the data quality needs of these uses is described in each monitoring activity s QAPP. e) Quality assurance activities are designed in the most cost-effective fashion possible without compromising data quality objectives. 2.1 Principle components and tools of the quality management system The primary QA planning and implementation components include a QMP, establishment of data quality objectives, QAPP, SOP and QA status reports. The components are listed below. Section 8 of this document discusses in detail staff responsibilities for the development of each component. Section 9 of this document covers the tools required for their implementation Quality Management Plan (QMP) The VADEQ WD QMP describes policies, procedures, and systems governing program specific data collection activities. It serves as the general document for QA operations. The QMP will be reviewed annually and revised as necessary Data Quality Objectives Data Quality Objectives (DQOs) are statements of the quality of environmental data required to support program decisions or actions. DQOs establish the level of risk or uncertainty that the 15

16 program is willing to accept in the environmental data in order to make a defensible decision. The VADEQ Quality Assurance Coordinator uses EPA QA/G-4 guidance for the Data Quality Objectives process when developing DQOs and is submitted to WD management for review and approval. DQOs are updated as needed to reflect changes in environmental policies as defined by management. DQOs for the water quality monitoring program are intended to accomplish the following: 1) Clarify the project objectives, 2) Define the most appropriate types of data to collect, 3) Determine the most appropriate conditions under which to collect the data, and 4) Specify the level of uncertainty that is acceptable as the basis for establishing the quantity and quality of data needed Quality Assurance Project Plans Effective management of a data collection program requires periodic assessment of the quality of the data being obtained to establish a basis to determine when and if corrective action may be needed. To ensure that this assessment occurs, all environmental monitoring planned or conducted within the WD shall have an associated QAPP. The QAPP shall ensure that: a) The level of data quality needed is determined and stated prior to data collection; b) All environmental data generated and processed will reflect the quality and integrity established by the QAPP. The program QA Officers shall notify the Project Managers immediately of any problem areas identified. The QA Officers will jointly outline necessary changes and Project Managers will institute the corrective actions. The program QA Officers will conduct a follow-up review of the required changes. Project managers verify that the identified problems have been corrected. The project plan is used as a guidance document for Project Managers, who are responsible for the development of QAPPs for all special studies, investigations, and intensive surveys conducted by VADEQ. Any project plans which are developed externally or internally will follow the EPA Requirements for Quality Assurance Project Plans for Environmental Data Operations, EPA QA/R-5 guidance document and submit them to the program QA Officers for approval prior to initiation of data collection activities. The office of WMA has developed an example template that follows the EPA Requirements for Quality Assurance Project Plans for Environmental Data Operations, EPA QA/R-5 format to aid staff and external organizations in the project plan development and review process. The QA Officers review and approve submitted QAPPs in the context of the program s DQOs. Reviews shall follow the QAPP review checklist listed in the EPA Requirements for Quality Assurance Project Plans for Environmental Data Operations, EPA QA/R-5 guidance document. Project managers will update project plans for special studies as needed and resubmit the plans to the program QA Officers for review and approval. The Program QA Officers will review WD 16

17 project plan annually and update the document as necessary. Updates will be reviewed by a panel consisting of monitoring staff and managers and approved by the Program Managers Standard Operating Procedures The use of Standard Operating Procedures (SOPs) in the WD serves as a mechanism to ensure comparability across programs environmental data collection projects. WD SOPs are incorporated into the WD QAPP and maintained by program QA Officers. SOPs detail the work processes conducted or followed within the program. The SOPs document the way activities are to be performed to facilitate consistent conformance to technical and quality system requirements and to support data quality. SOPs are intended to be specific to the program whose activities are described and assist the program to maintain its QA/QC processes. The best written SOPs will fail if not followed. Therefore, the use of SOPs needs to be reviewed and reinforced by the monitoring staff managers. Current copies of SOPs also need to be readily accessible for reference in the work area of those individuals actually performing the activity, either in hard copy or electronic format. To ensure availability, SOPs are available on DEQnet; an internal webpage designed to provide all the necessary documents required by VADEQ staff to conduct their daily operations. SOPs need to remain current. Whenever field procedures or analytical requirements are changed, the SOPs should be updated, reviewed and re-approved as soon as possible rather than waiting for an annual review. Changes or modifications may be made only to the pertinent section of a SOP, but the process must indicate the changed date and/or revision number in the document control notation. It is the responsibility of the program QA Officers to ensure that WD program policies and procedures are current and any changes communicated to the program staff to implement in their environmental data operations. SOPs undergo annual review to ensure any procedures not updated to reflect changes in field procedures or analytical requirements are brought up to date Quality Assurance (QA) Status Reports The WD QAPP for data collection will include the frequency, content and format of the required QA status reports. The Quality Assurance Coordinator or program QA Officers, submit QA status reports to the regional Program Managers and used to help track QA progress. Whenever possible, status reports will be produced quarterly and will address the following elements if applicable: 1) Changes that occurred in program activities (sampling, QC control measures, analytical methods). 2) A summary of performance and system audits as they apply. 3) Any corrective actions taken. 4) Any organizational changes. 17

18 5) Reports of the assessment of data quality indicators (precision, accuracy, completeness, representativeness and comparability). 3.0 PERSONNEL QUALIFICATION AND TRAINING 3.1 Training Policy All VADEQ personnel associated with Water Quality Monitoring and DCLS personnel who generate data must have adequate knowledge and skills in their technical specialties and applicable quality assurance practices to ensure quality data is generated. The VADEQ WD has developed and implemented a program of internal training to ensure staff has the appropriate knowledge and skills to perform their assigned responsibilities. 3.2 Training Qualifications and Documentation Entry level training is provided for new employees to ensure quality-related qualifications in field methods (such as instrument operation, approved sample collection, preservation, handling, field testing, quality assurance procedures) and in computer skills such as station establishment, sample scheduling and data entry and retrieval by Central Office personnel. Training in field methods is provided by the Quality Assurance Coordinator or designee and experienced regional personnel. A team of qualified personnel provides training in computer skills and all training documentation is retained in the office of training. In addition, the WD requires staff to undergo periodic training and recertification WD program s SOP. New hires must successfully complete the training modules before they collect chain of custody samples and no later than 12 months after their date of hire. After successfully completing the SOP training, field personnel are required to pass a retest, and take a refresher class if needed, every two years thereafter. Any existing staff person who does not successfully complete the training must discontinue collecting water quality samples and be retrained and retested until they can successfully complete the testing. New hires that do not successfully complete the training are paired with a mentor until they can successfully complete the testing. The training course consists of a combination of a repeatable video format and hands-on training. The course content includes training on all aspects of the WD SOP as well as the use of the water monitoring module of the agency database (CEDS) and chain of custody procedures. 3.3 Continued Proficiency To ensure continued proficiency in QA/QC procedures an annual field audit of all field sampling staff is conducted by the agency Quality Assurance Coordinator or designee qualified to perform audit tasks. The aforementioned certification program will require re-certification in field methods every 2 years. 18

19 3.4 Laboratory Personnel Training A written position description for each job in the laboratory is kept on record within the laboratory division. The position descriptions include the knowledge, skills, abilities and duties required of the position. A performance plan is prepared annually for each employee and their performance is evaluated by one interim and one final evaluation. Training is conducted at the division and group level. Performance evaluation samples are routinely used to determine proficiency in an area. It is the responsibility of the group manager to ensure orientation and rotation of workstation schedules. The division maintains a training record documenting each employee s credentials regarding education, seminars, workshops and on-site training. In order to assure competency and the ability to work independently, each employee is required to demonstrate completion of the following requirements: 1) Instruction in or prior knowledge of sample preparation, analysis and instrumentation principal associated with the method. 2) Instruction on the principles of laboratory safety associated with the method including review of associated MSDS forms. 3) Has read and understands the methods and SOPs associated with the analyses. 4) Instruction in or has prior knowledge of the instrument for the method. 5) Demonstrated performance of the method under the direct supervision of the trainer. 6) Instruction in or has prior knowledge of instrument and computer maintenance. 7) Independent successful completion of demonstration of capability. 8) Independent analysis of three sets of samples. 19

20 4.0 PROCUREMENT OF ITEMS AND SERVICES Revision: Quality System Requirement for Items: Conducting sufficient planning activities ensures purchased items meet predefined standards and specifications for quality. Technical staff directly involved in the use of the items will decide if items meet the necessary quality standards required to generate quality data unless a specific quality standard is specified in a regulatory document such as an analytical method. Standard and specifications, if not predefined, are developed in the planning process and included in the program QAPP. Upon receipt of purchased items, the monitoring staff inspects each item for adherence to the specifications required by the program QAPP. Specific guidance is available in the program SOPs. The program QA Officer monitors and summarizes QC data to relay to Program Managers the effectiveness of the item to provide data consistency and exclude external contamination. Data summaries are provided to the Program Managers for review. 4.2 Quality System Requirements for Services VADEQ personnel conduct all services related to water quality monitoring activities in-house. 20

21 5.0 DOCUMENTS AND RECORDS Revision: Identification of quality-related documents and Records Quality-related documents and records consist of QMP, QAPPs and SOPs and in the regional offices, field data sheets, and calibration/maintenance logbooks. All monitoring staff has access to these documents and records. Organized and well-maintained files are critical to the proper functioning of programs within the Water Division. 5.2 Maintenance of Records Each program QA Officer is responsible to ensure the program s QMP, QAPP, SOP and other specific quality practices are stored in the Oracle database and made available to outside interested parties through VADEQ s FTP site. Each regional office Program Manager is responsible for developing a master document log in order to maintain a comprehensive and current inventory of the program related field records. The DCLS QA Officer is responsible for the maintenance of laboratory QA documents as specified in their Project Plan. All the documents and records are archived in a safe and secure place and special care is taken to preserve the integrity of documents. Currently, the regional offices enter field data into VADEQ s central database, CEDS, where the data is secure and retrievable. Regional offices keep all hardcopies of field data sheets, calibration and equipment maintenance log sheets on file for seven years after which the regions dispose of the records. Plans are underway to modify the Oracle database to capture calibration and instrument maintenance. Once the database modification is complete, the regions will dispose of hardcopies of calibration and instrument maintenance every seven years as well. The Quality Assurance Coordinator will review the QMP, QAPPs and SOPs annually. Revisions to remove obsolete practices and include new field techniques are made as needed and reviewed by a committee consisting of key WQM staff from the central office and regional field offices. Final approval of the Quality Control documents is the responsibility of the Director of the Water Division. Each new QA document is clearly identified with revision date and version identification. The current document is then issued to all regional water quality monitoring managers for distribution to field personnel who should dispose of all previous versions. To ensure documentation of historical water quality monitoring practices, a copy of all documents are stored and available to VADEQ personnel via the CEDS database. Because routine samples collected for the WMA are not utilized for legal purposes, formal chain of custody procedures is not necessary. However, samples must meet specific criteria as outlined in the DCLS QAPP in order to be analyzed. DCLS sample and record management personnel reject samples not meeting those criteria. Samples requiring chain of custody follow procedures outlined in the WMA SOP manual. 21

22 6.0 COMPUTER HARDWARE AND SOFTWARE Revision: 7 The exchange of data between the regional offices, central office, DCLS and other laboratories, and the EPA is vital to many of VADEQ's missions. VADEQ utilizes a Comprehensive Environmental Data System (CEDS) which was designed to store all the data generated by the agency. The CEDS database was designed to have a unique module for each of the environmental media monitored by the agency. Teams were selected from each media to work with developers to ensure their module was designed to meet core business needs. CEDS is on an Oracle base dual client server system allowing complete backup of the system at all times and seamless transition from one server to the other in case one system fails. The Oracle database is compatible with the DCLS Laboratory Identification Management System (LIMS) and EPA STORET and the new WQX database enabling better connectivity with those entities. The Office of Information Systems (OIS) is responsible for managing VADEQ's technology infrastructure and components. All information management system development, improvements, and updates are submitted to a CEDS steering committee consisting of VADEQ personnel from each media who generate and utilize the data. The tasks are prioritized and given to OIS for implementation. Prior to implementing changes in the production database, it is thoroughly tested by groups picked from the respective media to ensure changes perform as expected and meet the user requirements. To ensure compatibility with existing programs, OIS staff review and install all software and hardware purchases within the agency. VADEQ's data standards and regulations vary within water quality monitoring programs, some of which receive funding from federal grants. Every water quality monitoring program is required to have a QAPP specifying their specific standards and regulations. However, a Quality Assurance module has been included in the CEDS system including station and parameter specific range checks, high and low acceptance criteria for data entry screens and inter-parameter checks. Error reports are readily available to all data users for review. 22

23 7.0 PLANNING Revision: Planning Goals and Objectives As outlined in the 2007 Virginia Water Quality Monitoring Strategy, the goal of the strategy is to provide representative data that will permit the evaluation, restoration and protection of the quality of the Commonwealth s waters at a level consistent with such multiple uses as prescribed by Federal and State laws. The planning objective of the WQM is to ensure sufficient quantities of quality data are collected to support the use of the data. The planning process is intended to document all activities related to the generation, analysis, and use of data. 7.2 Identification of Data Users and Suppliers VADEQ water quality monitoring program data users include: environmental assessment planners and managers, EPA, regulated facilities and other external groups. Data suppliers include sampling groups (such as citizen monitoring groups), environmental agencies, contract laboratories as well as other external data generators. 7.3 Scheduling and Resources Each regional office submits annual monitoring plans based on VADEQ s water quality monitoring strategy. The current monitoring strategy, revised in 2007, will undergo scheduled reviews in the future and be further revised as needed. Each region is responsible for identifying the available resources and ensuring those resources are utilized in the most efficient manner to meet VADEQ s monitoring strategy goals. 7.4 Performance Criteria The WQM planning process specifies the performance criteria for measuring quality. Data obtained from WQM programs is assessed, verified and qualified according to its intended use. Criteria or measures should include: 1) The objective for measurement data in terms of precision, accuracy, completeness, comparability and representativeness, 2) Data quality assessments, 3) Validation/verification of results, and 4) Documentation establishing the requirements for those objectives. 7.5 QA/QC activities The WQM planning process specifies which QA and QC activities are necessary to assess the quality performance criteria (e.g. QC samples for the field and laboratory, audits, technical assessments, and performance evaluations etc.). Key variables that determine or directly affect 23

24 the quality of results are identified and controlled according to the specifications determined during the planning or design process. 7.6 External Data The VADEQ must also coordinate the collection and use of environmentally related data across numerous government agencies, contractors, academic and private organizations and trained volunteers. Close coordination and planning is essential to ensure that the data are of sufficient quality to support the intended use. The VADEQ encourages data sharing whenever possible, providing adequate data quality indicators are available so that quality of data are sufficiently known to support the applicable decisions. 7.7 Analysis, Evaluation and Assessment of Data The WQM QAPP serves as the basis for the analysis, evaluation, assessment against the intended use, and quality performance criteria of acquired data. Data not meeting the criteria as specified in the project plan is flagged in the database. 7.8 QAPP reviewing, approving, and revising Any WQM project (including special studies) involving the collection of environmental samples by VADEQ personnel or external organizations, is required to have an approved QAPP prior to collection and analysis of any samples. QAPPs are reviewed and approved by the program QA Officer and QA Coordinator. The VADEQ WQM QAPP will be reviewed annually, updated if needed or revised within 30 days of significant changes. 24

25 8.0 IMPLEMENTATION OF WORK PROCESSES Revision: Operating Policies and Procedures The WD has developed and uses the appropriate policy and procedures as needed for its programs. The QAPP and SOP for water quality monitoring are documented in writing and are accessible to all persons involved in the implementation of the program. DCLS has also developed its analytical method manual. Where the program uses data generated by external entitles, the external data undergoes the same evaluation and documentation procedure, as would WD program data before it is used by the WD. This ensures that data fit within the margins of error constraints as established by the VADEQ program management. 8.2 Program Implementation Program data operations are implemented in accordance with an approved QAPP. Changes to the QAPP are documented and approved in writing through an amended QAPP. The QAPP may be revised as necessary or revised and reissued within 30 days of significant changes, whichever occurs first. The latest approved version of the QAPP will remain in effect until a revised version has been approved. The Program Managers oversee the program. Program Managers work in conjunction with program QA Officer to ensure that project proceeds in the correct direction and generates the appropriate documentation. 8.3 SOP Implementation All standardized procedures used for sampling and analytical techniques are documented in the program SOP. The SOP ensures standardization of a task for consistency in data generation across the regions. The program QA Officer, who is familiar with the procedures being described, writes the program SOPs. A panel consisting of experienced program monitoring staff and managers from central and regional offices reviews the SOPs. The Director of Water Division approves the final documents. Personnel who perform an activity or function use procedures covered by the appropriate SOP. It is the responsibility of the regional Program Managers to ensure program SOPs are properly implemented. It is the responsibility of the individual users to follow the procedures contained in the SOP, or document any deviations. The implementation of SOPs is assessed through internal field audits. A list of the applicable SOPs is provided in Appendix A. 25

26 8.4 Implementation of the Analytical Methods Manual DCLS analytical personnel use the analytical methods manual to document procedures. The group managers are responsible for ensuring personnel utilize approved methods as specified in the analytical method manual. Implementation of the analytical methods manual procedures are ensured through blind performance evaluation samples and a NELAC accrediting entity. Under Virginia Administrative Code , Virginia has implemented a NELAC type laboratory accreditation program with DCLS being the accrediting authority for the Commonwealth. VADEQ will no longer conduct biannual lab audits on DCLS and non-exempt laboratories. The Quality Assurance Coordinator or designee will regularly conduct audits of laboratories exempt from DCLS accreditation/inspection as outlined in 1 VAC who submit water quality data to VADEQ. This will ensure data submitted by such a laboratory meets DQOs for the WD program which utilizes the data. 26

27 9.0 ASSESSMENT AND RESPONSE Revision: 7 This section of the QMP describes how the VADEQ OWP will assess the effectiveness of its quality management system by using a variety of technical reviews and performance evaluations and QA audits to make sure that the procedures in this QMP are implemented successfully. 9.1 Review of VADEQ Quality Assurance Program The program QA Officer will conduct internal assessments of their respective program Quality Assurance program every two years. The evaluations are submitted to the regional Program Managers in a written memo. The reviews are intended to accomplish the following objectives: 1) Identify any data quality problems. 2) Propose recommendations for resolving quality problems and confirm implementation and effectiveness of any recommended corrective actions. Assessment personnel are knowledgeable in all areas of water quality monitoring and independent from regional personnel to avoid conflict of interest. Assessment personnel attend training seminars, workshops and forums to maintain assessment proficiency. Assessment personnel will have access to all Program Managers, records, and documents pertaining to water quality monitoring. Assessment personnel have the authority to modify the database for QA purposes. All assessment summaries are given to the regional Program Managers for their review. The regional Program Managers will prepare a written response to the reviewer s memo. If the program QA Officer recommends corrective actions, the regional Program Managers should address those recommendations within 30 days and include a schedule for making any appropriate changes in its quality assurance procedures. Once the corrective actions are implemented, the program QA Officer will document the effectiveness of the corrective actions; either requesting further action or indicating the problem has been resolved. If a regional Program Manager disagrees with the program Quality Assurance Officer s findings and recommendations, a panel of regional monitoring personnel familiar with the issues will be assembled to resolve the issue. Should the panel be unable to conclude the issue, the WD Director from central office will be asked to arbitrate a resolution. 9.2 Technical Systems Audits (TSAs) A TSA assesses the sampling and analytical quality control procedures used to generate environmental data. The program QA Officer will use TSAs to evaluate the procedures used by field monitoring staff and laboratory contractors. TSAs may entail a comprehensive on site evaluation of field equipment and laboratory instrument calibration; record keeping procedures; and data validation, data management and reporting. 27

28 9.2.1 Laboratory TSAs DCLS has instituted a separate division to conduct TSA of environmental laboratories using procedures outlined by NELAC. VADEQ will no longer conduct TSA of DCLS laboratories and most contacted laboratories who submit data to the agency. DCLS will conduct TSAs of nonexempt laboratories who submit analytical data to VADEQ every two years, or as needed. Citizen monitoring and related laboratories exempt from the DCLS inspection (1 VAC ) and who submit water quality data to VADEQ are inspected by VADEQ once every two years, or as needed. The primary goals of TSAs are to review the laboratory organization, operation and capabilities, determine the reliability of the data and note corrective action for any apparent deficiencies. The program QA Officer is responsible for planning and conducting the audits and reporting the findings to the laboratory directors and VADEQ Program Managers Field TSAs Oversight of field operations is an important part of the quality assurance process, and the program QA Officer conducts QA audits of field sample activities, both for its own field operations and its contractors. Field TSAs are conducted for each regional office annually and the findings reported to the regional Program Managers Performance Evaluations Performance evaluations are conducted to assess the ability of a laboratory or field measurement system to obtain reliable data. The evaluation consists of providing a reference or blind sample to the laboratory for analysis. The performance evaluation sample contains known concentrations of chemical constituents or pollutants of interest, normally found in the appropriate media. The analytical results obtained by the laboratory are compared to the known concentrations of the specific parameters contained in the performance samples to determining if the laboratory demonstrated its ability to properly identify and quantify pollutants within established or calculated control limits. 9.3 Data Quality Evaluations Data Quality assessments A Data Quality assessment (DQA) is a statistical process used to determine whether the quality of a given data set is adequate for its intended use. The program QA Officers routinely review and validate data generated by DCLS and other contracted laboratories. These data validation activities use checklists, standard operating procedures and standardized qualification codes to determine data quality. The use of checklists and SOPs help standardize the data validation process and minimize any discrepancy that may result between data validators within WD and DCLS laboratory personnel. The data quality assessment SOP and checklist are listed in Appendix B. 28

29 9.3.2 Data Completeness A data quality audit assessment primarily involves a completeness check of the generation of field and analytical data. The VADEQ Oracle database automatically checks data entry for field results and laboratory results for parameter completeness. Incomplete field data is allowed into the database as instrument failures can occur resulting in missing field parameters. The database generates an error report that is then reviewed by central office personnel. Incomplete analytical results are also allowed into the database, as analytical results are batch uploaded. The Laboratory Liaison is responsible for reviewing the report for the missing analytical results and for contacting either OIS to determine the cause of the problem or the DCLS for data corrections. 29

30 10.0 QUALITY IMPROVEMENT Revision: 7 The OWP actively supports quality improvement by encouraging the both VADEQ staff and DCLS laboratory staff to: 1) Continually evaluate the effectiveness of current procedures and practices. 2) Apply innovative approaches to maintaining integrity and accuracy. The above goals can be achieved by committing resources to the quality management system to enable the constant evaluation of the water quality monitoring program and individual staff performance. The quality management system is designed to identify opportunities for improving the measurement process. Improvement can take the form of preventing quality problems from occurring by adjusting current work processes or by seeking out better ways to do the work. The goal is to prevent quality problems from occurring or recurring. Every attempt is made to ensure quality assurance problems are identified and resolved quickly by encouraging open communication between field personnel and central office personnel as well as laboratory personnel and associated quality assurance officers. The program QA Officers is responsible for coordinating and evaluating water quality monitoring program quality improvement activities. The program QA Officers and regional Program Managers annually review all the QA activities of field staff, e.g. reviewing SOPs for adequacy and revising them if necessary. All deviations and discrepancies noted during the assessment review are corrected promptly. 30

31 APPENDIX 31

32 Appendix A List of SOP title and their locations SOP title Location VADEQ Ambient Water Quality Monitoring QAPP Central database, CEDS VADEQ WQM SOP Central database, CEDS QAPP for the VA River Input Monitoring Program QAPP for Chesapeake bay mainstem and Elizabeth River Water Quality Monitoring Program VA Tributary Monitoring Program QAPP VA CBP Non-tidal Network Monitoring Program QAPP Acidity in water DCLS building, room 327 Alkalinity in water DCLS building, room 327 Anions- Ion Chromatography DCLS building, room 327 Biochemical Oxygen Demand DCLS building, room 327 Particulate Nitrogen/Carbon DCLS building, room 327 Chlorophyll DCLS building, room 327 Color DCLS building, room 327 Free Cyanide DCLS building, room 327 Total Cyanide DCLS building, room 327 Cyanides amenable to Chlorination DCLS building, room 327 Fluoride DCLS building, room 327 Calcium Hardness DCLS building, room 327 Total Hardness DCLS building, room 327 Nitrogen - Ammonia DCLS building, room 327 Nitrogen - Nitrite and Nitrate DCLS building, room 327 Nitrogen Total Kjeldahl DCLS building, room 327 Oil and Grease DCLS building, room 327 Total Organic Carbon DCLS building, room 327 Particle size DCLS building, room 327 PH DCLS building, room 327 Total Phenols DCLS building, room 327 Particulate Phosphorus DCLS building, room 327 Total Phosphorus DCLS building, room 327 Silica DCLS building, room 327 Total Suspended Solids DCLS building, room 327 Total Dissolved Solids DCLS building, room 327 Settleable Solids DCLS building, room 327 Total Solids DCLS building, room 327 Sulfide DCLS building, room 327 Tannin and Lignin DCLS building, room 327 Turbidity DCLS building, room 327 Reactivity DCLS building, room 327 Nitrogen- Urea DCLS building, room 327 Sediment TOC DCLS building, room 327 Acid Volatile Sulfide DCLS building, room 327 Suspended Sediment DCLS building, room